Provider Demographics
NPI:1669520375
Name:ELLISTON, JASON TAIWO (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:TAIWO
Last Name:ELLISTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 BRIARCLIFF RD
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-3005
Mailing Address - Country:US
Mailing Address - Phone:201-833-1257
Mailing Address - Fax:
Practice Address - Street 1:935 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304-2731
Practice Address - Country:US
Practice Address - Phone:201-478-5824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06380500208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0038326Medicaid